The American Psychiatric Association (APA) publishes “Practice Guidelines” for the treatment of several mental disorders, including eating disorders, substance abuse, and schizophrenia. These manuals are intended to provide evidence-based guidance to mental health practitioners who provide health care.
One of the earliest of these issued guidelines, published in 2001, was devoted to the treatment of borderline personality disorder (BPD)1. A new version of these will be formally released in January—though preview summaries, on which this analysis is based, have already been released.2 The 2001 edition was 52 pages long. The 2025 version will be close to twice as long.
What can we expect to be different? A lot… and not very much.
What Won’t Change in the New BPD Guidelines
In 1980, the APA published the third edition of its Diagnostic and Statistical Manual (DSM) intended to define psychiatric disorders. This volume was markedly different from the two previous DSM publications, as its description of each disorder was defined by specific criteria. DSM-III was also the first edition to formally recognize and categorize BPD.
In the ensuing 45 years, DSM-IV and DSM-5 (and accompanying text revisions) have had only minor adjustments to the defining criteria. Thus, the introductory descriptions of BPD characteristics in the new Practice Guidelines will not differ substantially from the 2001 notation. However, there will undoubtedly be recognition of likely changes to a more dimensional definition of BPD (citing the degree of illness, the severity of impairment, etc.) that will surely influence the future DSM-6 edition.
Both Guidelines emphasize that psychotherapy is the primary treatment of BPD and that no medication has been approved specifically for its treatment. Since the 2001 publication, some pharmaceutical institutions have attempted but failed to achieve an FDA-approved indication. Research is continuing with some companies.
What Will Change
Probably the most notable difference in our understanding of BPD over the past 24 years is in the course of the illness. Long-term follow-up studies were limited. The 2001 Guideline stated that “cure is not a realistic goal,” going on to note that “in the largest follow-up study to date [in 1990], about one-third of patients with borderline personality disorder had recovered by the follow-up evaluation.” More recent studies now demonstrate that prognosis is much better, with remission and recovery rates significantly improving over time.
The subjects of stigma and discrimination, even among practitioners, were not mentioned in the 2001 publication. Although this area needs further study, these topics will apparently be acknowledged in the new version.
The biggest changes will be in the number of therapeutic approaches evaluated. The 2001 edition reviewed studies on the only psychotherapeutic systems that had demonstrated efficacy—psychoanalytic/psychodynamic psychotherapy and dialectical behavioral therapy. The 2025 report will assess more approaches, mostly those that are standardized and manual-based.
Likewise, more data on how medications can be useful in addressing specific symptoms will most likely be considered in 2025. The earlier presentation noted that “neuroleptics” (antipsychotic medicines) were the most used and the most efficient in treating “global symptom severity.” The new report suggests that the use of medications be time-limited and reviewed at least every six months.
The 2025 Guidelines will include a more systematic program of recommendations (known as GRADE), which balances benefits versus harm potentials. There will also be a method measuring the strength of supporting evidence, from high to low confidence.
The purpose of these updated Practice Guidelines is to provide clinicians with current evidence of treatment approaches that optimize individualized treatment for patients with borderline personality disorder.